Managing diabetes in primary care: 2016 recommendations from ADA

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The ADA has published the 2016 Standards of Medical Care in Diabetes.
The ADA has published the 2016 Standards of Medical Care in Diabetes.

Medical management of diabetes

For the best possible diabetes management, clinicians should combine behavioral, dietary, lifestyle, and pharmaceutical interventions to create the best regimen for their patients (B rating).

The majority of patients with T1DM should be treated with multiple-dose insulin injections or continuous subcutaneous insulin injection (A rating). Clinicians should also offer education on matching prandial insulin doses to carbohydrate intake, preprandial blood glucose levels, and anticipated activity level (E rating).

For patients with T2DM, clinicians should take a patient-centered approach. Patients who are newly diagnosed with T2DM and are overweight/obese should implement lifestyle modifications to lose 5% of their body weight. If lifestyle modifications on their own are insufficient to achieve glycemic goals, clinicians should add metformin therapy to patients' regimens (A rating).

If monotherapy at the maximum tolerated dose is unsuccessful over 3 months, clinicians should add a second agent to the patient's treatment (A rating). Sulfonylureas, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) agonists, or basal insulin should be considered based on the patient.

Insulin therapy should be used for patients with T2DM experiencing severe hyperglycemia that causes ketosis or unintentional weight loss (E rating); it should also be used for patients who are not achieving glycemic goals (B rating).

Cardiovascular risk factor management

Because atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality in patients with diabetes, clinicians should assess patients' cardiovascular risk factors at least once a year. Risk factors include dyslipidemia, hypertension, smoking, a family history of premature coronary disease, and the presence of albuminuria.

If a patient with diabetes has hypertension, lifestyle modifications (weight loss, a reduced-sodium diet, moderate alcohol intake, increased physical activity) and pharmacologic therapy (either an angiotensin-converting enzyme [ACE] inhibitor or an angiotensin-receptor blocker [ARB]) should be initiated (B rating).

To improve the lipid profile of a patient with diabetes, clinicians should recommend lifestyle medications including weight loss; reducing the intake of saturated fat, trans fat, and cholesterol; increasing the intake of ω-3 fatty acids, viscous fiber, and plant stanols or sterols; and increasing physical activity (A rating). For most people with diabetes aged 40 years and older, statin therapy is also recommended (A rating).

For patients with diabetes who have an increased cardiovascular risk (10-year risk >10%), aspirin therapy is recommended (C rating).

Microvascular disease screening and management

Patients who have had T1DM for ≥5 years, patients with T2DM, and patients with comorbid hypertension should be screened annually for diabetic kidney disease through urine albumin-creatinine ration on a spot urine sample and eGFR (B rating). A patient is considered to have albuminuria if 2 of 3 urine albumin-creatinine ration specimens collected over 3 to 6 months are abnormal (>30 mg/g). Intensive diabetes management may delay the onset and profession of albuminuria and reduced eGFR.

To reduce the risk of retinopathy, clinicians should work with patients to optimize glycemic control (A rating), blood pressure, and serum lipid control (A rating). Patients who have had T1DM for ≥5 years and all patients with T2DM should see an ophthalmologist or optometrist annually for a comprehensive eye exam.

Diabetic neuropathy can be prevented or delayed with glycemic control, but it cannot be reversed once it begins to manifest. Clinicians can prescribe pregabalin, duloxetine, and tapentadol to treat diabetic peripheral neuropathy; tricyclic antidepressants, gabapentin, venlafaxine, carbamazepine, topical capsaicin, and tramadol are other treatment options.

Patients who have had T1DM for ≥5 years and all patients with T2DM should have an annual foot exam using 10-g monofilament testing plus pinprick sensation, vibration perception, or ankle reflexes (B rating).

Diabetes care in the hospital

For diabetes patients who are hospitalized, inpatient glucose targets of 7.8 to 10 mmol/L are appropriate for most noncritical (C rating) and critical patients (A rating). The best method for glycemic control is continuous intravenous insulin infusion for critical care patients and scheduled subcutaneous insulin injections for patients not in critical care units.

Hospitals should have a standardized, nurse-initiated treatment protocol to address hospital-related hypoglycemia.

To optimize patient outcomes, patients with diabetes should have a discharge plan that is tailored to their needs (B rating). Patients should also have an outpatient follow-up visit 1 month after discharge.

Reference

  1. Chamberlain JJ, Rhinehart AS, Shaefer CF, et al. Diagnosis and management of diabetes: synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Ann Intern Med. Published online 1 March 2016. doi:10.7326/M15-3016.
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